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Dockwalk magazine's regular column, What Went Wrong, highlights a different marine accident each month, focusing on the lessons learned. We've received feedback that some readers would like to comment on it. So we're republishing it in the forum so you can have your say.

This month is about the fire on board M/Y Lady Candida.

In July 2007, a fire started in the laundry area of the 29.46-meter M/Y Lady Candida when lint that had accumulated in the dryer’s ventilation system ignited. The air vent was connected behind the machine, making it very difficult to access for cleaning. Although the previous crew had experienced overheating before, the Marine Accident Investigation Branch (MAIB) casualty report states that “this information was not passed over during a short handover between crews in 2006.”

The stewardess first brought the fire to the captain’s attention around 4:30 p.m., when she smelled smoke. The vessel was about three miles off the southwestern coast of Corsica. The captain immediately checked both the galley and the engine room, but it was a deckhand who found smoke coming from a laundry vent near the bow. He opened the emergency escape hatch and black smoke was immediately apparent. He discovered a dryer with burning clothes inside and extinguished the fire with a dry chemical fire extinguisher.

Unfortunately, by opening both the escape hatch door and the dryer, a fresh supply of oxygen caused the fire inside the ventilation system to spread quickly to an adjacent stateroom. According to the MAIB report, “The captain instructed the senior deckhand to go to the engine room and start the fire pump while he attempted to fight the fire through the open hatch using a portable extinguisher.”

However, the fire pump could not be started. The back-up emergency pump was stowed in the lazarette – the door to which was blocked and the pump itself was stored behind other bulky gear used more often. Despite best efforts, the fire quickly spread.

At 4:40 p.m., the mate donned the only set of SCBA gear and continued to fight the fire while the captain issued a mayday and directed the deckhand and stewardess to evacuate the guests to shore in the tender. It was not long before the crew’s efforts obviously became futile. At 4:45 (a mere 15 minutes from the time the fire first was noticed) the crew prepared to abandon ship.

The fire blocked access to all but one of the yacht’s life rafts. During its deployment, unbeknownst to the crew, the sea anchor also had deployed – the crew were unable to maneuver the raft away from the burning boat and the thick smoke. “Concerned by the proximity of the fire, which had now spread along the entire vessel and had started to melt the aluminum superstructure, the crew entered the water and pulled the life raft away from the burning vessel,” the MAIB report stated.

Fortunately, a nearby sailboat had dispatched its tender after hearing the mayday. When it arrived on the scene, the crew had managed to move the life raft only 30 feet from the burning vessel. The Samaritan tender towed the crew safely away.

By the time a fire-fighting vessel arrived on the scene, the yacht was almost entirely engulfed in flames. The vessel was a total loss, but no major injuries or fatalities occurred. In its review, the MAIB noted that the captain lacked both the proper training and support to reasonably manage the situation.

“The captain had twenty-two years experience on yachts…[but] had not completed an STCW’95 approved fire-fighting course,” the MAIB found. Because the yacht did not have an engineer on board who could easily diagnose the problem with the emergency pump that was cited as another contributing factor in the crew’s inability to contain the fire.

The casualty report also indicated that the fire went undetected for so long because smoke detectors on board were powered by nine-volt batteries with no alternative power source. Several detectors in the immediate vicinity of the fire’s source had dead batteries, so no audible or visual alarm was activated until the fire had spread to an area with a working detector.

Although the report is critical of the captain for a series of mistakes, the MAIB notes that owner apathy toward providing sufficient vessel downtime for training, regular maintenance, safety drills and adequate crew rest played a role in the chain of events. This is an issue many crew attempt to navigate with their yacht’s owners.

The report states that because of a rough and longer than expected passage from the Caribbean, the crew had been without a day off for more than a month. So captain fatigue is cited as one of the causes. Because the vessel had no viable management, the captain performed all the administrative and engineering duties on top of his heavy workload associated with back-to-back charters. The captain reported that he “had few periods of rest and managed only about five hours sleep in each twenty-four hour period.” To make matters worse, the report states that, “He was often informed that there were insufficient funds in the company accounts to pay for vessel maintenance.”

Also in the official report’s findings was that “a significant number of departures from the requirements of LY1 were identified…. The management and operation of [the vessel] was left almost entirely to her captain; her owners had [failed to assume] a major responsibility for ensuring that the captain had the necessary experience and support to safely manage the vessel. There was no oversight by a yacht management company with an understanding of the requirements of LY1 and other national regulations, which would have provided support to the captain and an independent verification of the vessel’s compliance.” Though a captain ultimately may be responsible for the vessel’s safety, the vessel’s owner also is accountable.

To further illustrate the dire irresponsibility of the owner, when the crew arrived on shore, “They did not have any money or personal belongings except the clothes they were wearing. The captain contacted the legal representative of the beneficial owner … for assistance, but was told that he should be capable of looking after himself and his crew.”

Was the start of this fire a freak accident? Yes and no. “The accident on board Lady Candida was the first example … reported to the MAIB of a fire which had originated in the laundry of a large charter yacht. However, since 1991, seven fires in the laundry spaces of other UK-registered vessels have been reported to the MAIB.”

So in addition to the lessons to be learned from this incident, careful attention to laundry ventilation should make the list. As with each scenario presented, crew need to make a point of ensuring all safety precautions are in place and practiced. If not, make sure to address concerns with the captain (and, if need be, the owner) to ensure that you’re not ill prepared in a life-threatening situation.

The laundry has been the source of many vessel fires including srveral cruise ships and the aircraft carrier Nimits last winter. Lint screens in driers aren't completely effective and the ducting away from them is difficult to clean. What is most striking here though is the manner in which the vessel was operated. It exemplifies why my CV has started with "I am looking for an owner more so than a boat" for many years now.The real question to ask here is had anybody been killed, would the owner have been held criminally liable? Does anyone know the status of the insurance claim? Did Minimum Safe Manning apply to this vessel at the time of the accident, and did the failure to meet and comply with MSM cause a denial of claim?

Janine, I think you should go back and reread the MAIB report through a different set of glasses. There are several issues raised in the report that are not even mentioned in your version of events.
The captain was not certificated and was unqualified to serve as master. His lack of skills, training and judgement are at the root of this casualty. Both MCA and RYA issued a license despite his lack of firefighting training. Both of these organizations share responsibility for setting this person loose on the industry.
The vessel sailed on a charter without having the required crew onboard, another inexcusable failure of leadership and resonsibility on the part of the master. Did the "manager" even know the engineer had quit? If so then the blame is shared between them. If not then more blame falls on the captain and his phenomenal lack of judgement and leadership.
The captain did not know how the systems on his vessel operated. He did not train the crew or drill. He did not have the required "mini-ISM" in place, a safety management system that might have highlighted his and his crew's inability to deal with the real-life risks of their employment and the responsibilities that go with it. While the MAIB can choose not to lay blame on any individual, the facts are that lacking any external oversight (which many yacht captains resist anyway) one person made the decision to leave port fatigued, undermanned, unqualified, and unfit for the role he was happy to accept payment ... the captain.
A good manager would have removed that captain before his incompetence could have had any impact but that didn't occur. Since no one else onboard that vessel gave the order to cast off in a condition which maritime courts have repeatedly determined to be unseaworthy, the blame for this debacle lies totally on the shoulders of an incompetent and unqualified captain.

We should have included the byline, the column is written by Kelly Sanford, not Janine. As this is a magazine column reprinted here, Kelly had a limited word count and had to summarize the MAIB report to fit on one page and as she told me "a lot went wrong here." It is mentioned in the article above that the report found the captain lacked the proper training and support to manage the situation.

Possibly you're coming down a little too hard on the Skipper. The article seems to state the vessel was/is starved for funds. We both know this is the first step on the road to "shipwreck". A small line item in the vessel budget labeled Preventative maintenance would have averted the difficulty if the person in charge of machinery had the freedom to make repairs to items before they fail !

Thank your for your remarks. I did not mean to diminish the captains culpability at all. You are correct that his lack of proper training is the 800 pound gorilla in the casualty report, and should certainly be a part of this discussion. It is always alarming to hear about captains who accept offers or deceive owners into making offers to run boats and programs for which they are not properly qualified. (The WAVE DANCER incident was another classic example of the same problem. )

Having read a number of reports, this one really stands out in that it is very critical of the owner and assigns a good part of the blame to the owner and his agents. Particularly now, with a sour economy, owners like this one are not all that rare. To save money some owners will economize the crew to the point of endangering them either with an underqualified captain (or engineer), an unrealistic schedule and/or insufficent funding.

As both you and Kate have already pointed out, there was much more to the 25+ page report than could be covered in my short column, so I am attaching a link to the full MAIB report, which describes in detail the chain of events. There is a lot to be learned from this incident and anyone hoping to get a full appreciation for the numerous instances where things went wrong should read the complete report.

"Possibly you're coming down a little too hard on the Skipper." Not hard enough in my estimation. The fact that the operation was poorly funded and received virtually no support by the owner or his "manager" is secondary to the fact that the captain was unqualified and knew it, he was uncertified and the MCA and RYA should have known it, and the captain ignored his responsibility to operate the vessel within the law. He did not know how the emergency systems on his vessel functioned yet he chose to sail without an engineer. He did not know how and from where to start a fire pump yet did not perform drills to ensure the safety of his crew and passengers. The Lady Candida was unseaworthy because it was not properly manned or commanded. The captain did not have a gun to his head when he chose to cast off without an engineer, without a valid license, or the ability to respond to an emergency for which he should have been fully prepared and was responsible to manage. What is shocking is the number of articles written since the casualty that place blame on the owner and the so called manager, yet stop short of placing responsibility squarely where it lies. Neither the MCA or RYA have made any comment regarding their culpability in this matter. Don't blame the owner, as far as he knew everything was just fine. No one stopped the boat from sailing did they? The owner didn't welcome the guests onboard, and the manager didn't cut the lines with an axe. The system broke down when that captain was given command of Lady Candida, it collapsed completley when his passengers and crew most needed the skills and training his license implied.

Chief, even the unqualified captain comes down to the owner/management company who hired him being unqualified. The entire operating atmosphere of a vessel begins with whomever is writing the checks. If the operational environment is one of "Profits above all else" then that filters down. I have been admonished for "wasting time and dirtying up the boat and gear" on training and drills. I walked off that boat that day. These are the same type people who will seek out an unqualified captain who either doesn't know better or care, or who can be ordered into doing things incorrectly because they have such limited employment options.

The captain of the Lady Candida did not walk off the boat. He chose to leave the dock, and therein lies the root of this casualty. A competent and ethical master would have refused to sail or as a last resort, walked off. We know he was neither competent or ethical and that is the reason I take the position I do. The owner did not make this guy a fraud, the manager's failures did not make this guy a fraud. The captain himself knew he was incompetent and unqualified, the MCA and the RYA were supposed to know, they had the documentation to know, and had the professional knowledge to know the captain was incompetent. It is disturbing to see so many in this industry trying so hard to divert the responsibility for this from the one person who was in a position, and had the ultimate responsibility, to prevent it from happening. As I have written repeatedly, no matter how cheap the owner or no matter how wretched and incompetent the manager, it was the captain who made the choice to leave the dock with innocent men, women, and children onboard a vessel with a crew that was not fit for sea.

"Chief, please tell us how many jobs you have walked out on." Why don't you say what you really meant to say? I think the unwritten part of your question says more than the written part. If what your question implied was "it is easy for you to tell someone else to walk off but do you have the guts to do it?" then the answer is yes. I have been fortunate to work for professional operations and have never had to "walk off" in the middle of a trip. I have (at the end of a trip) quit a couple of companies that wanted to economize more than I judged to be reasonable. I have delayed several ships from sailing when I have not been satisfied with the conditions onboard because making that judgement call is part of my duties and responsibility, it is what I get paid to do. If what you didn't say or ask was "but if I walk off I have lost my job" then welcome to the world of adults, that is what having a license is about, it means you have the integrity to demand professionalism from the owner, the manager, the crew, and yourself. Maybe I have been lucky, I spent more than a few years away from sailing to hold down the left seat of an airliner. That is where I learned that making the right decision was more important than making the trip. All the pressure was still there to go, it was intense at times but the training and the professionalism of the company and the organizational culture permitted - demanded - that safety was the overriding consideration. When I returned to sea for the Gulf War I took that culture with me and will not compromise it just to make a few dollars or look good for someone who doesn't even understand what professionalism means, much less leadership.

Yes, Chief you have eloquently spelled out the bottom line here. In the end it is the captain who is responsible, and if the captain is not qualified he has no business taking the position of master on a vessel if he does not have the qualifications or training. Even if he is a consummate and brilliant captain, "things" can happen and if you don't have the paper the owner can lose a fortune because insurance companies are always interested in reasons not to cover a loss.
Now, the above doesn't mean paper talks and sea time walks, to the contrary. Tickets are one thing but if I were a maritime insurance agent sea time, real sea time, and varied (towing, the oil industry, ferries, etc...) would rank higher than a fellow who'd only worked on a yacht that was docked 80 percent of the time.

"In the end it is the captain who is responsible,..." And how they love to write that in internet forums. They wax eloquent about the majestic responsibilities they shoulder on behalf of owner and crew and the whole "lonelieness of command" thing. At least until somethng happens that is, then all of a sudden it is the fault of the owner, the manager, the mate, or someone or somethiing other than themselves. Heaven forbid any names are mentioned or the MCA recalls the license they issued so lightly. Any guesses as to what the captain of the Lady Candida is doing right now? Did the MCA pull his ticket? Did they even make him take a firefighting course? We will never know, as an industry we don't want to know. The discretion surrounding ownership has become a fogbank in which to hide the incompetent and their actions. It is little wonder the underwriters are usurping the role of flag states in determining who they will alllow to serve onboard a yacht. But when the flag or a storefront school issues a license to someone who is unqualified, the underwriter becomes as much a victim as the owner and his "guests." Better to risk sinking or toasting a few charter guests than embarrasing the MCA or a captain. The Lady Candida should be a wakeup call to all owners and managers as well as storefront license schools and those who think it is wrong to show our "dirty laundry" and publish incident reports or names of those who had responsibility at the time of an accident. The press names drivers in car wrecks, doctors charged with malpractice, those arrested for public drunkeness, victims of circumstance, and a host of other newsworthy events that happen to the guilty and the innocent. The aviation industry thoroughly documents and distributes incident reports to help prevent similar occurences. Only in this industry do we submerge every detail, even if it assures we will continue to make the same mistakes. Do we have to kill 12 people before the light comes on?

On the MAIB website there are no accident reports for yachts in 2009 ether completed, preliminary or in progress. Unless I'm being thick and someone can point out the right place to look in which case I will happily stand corrected.

Cheif- Wow. I just have to say that your last comment really sumarizes the perspectives I get from yacht owners and insurance professionals ALL THE TIME. Well said. I am amazed at how many people assume that information about marine accidents is carefully documented and that the captains involved are properly vetted and diciplined when necessary and that this information is made public. The shocking truth is that none of these things are done with any reliability. Unless you have first hand knowledge about a specific incident, it is VERY difficult to get access to a report. If you think the MAIB is bad, the USCG is much worse. To get a full casualty report, you basically have to track down an incident report number (not easy to do) and then request a copy in writing from the freedom of information act officer in DC. I am still patiently waiting for reports requested months ago. I can see why you would be angry and frustrated. There is almost no transparency in marine accident reporting and accountability. What is most unfortunate, is that there are valuable lessons to be learned from these reports, but the people who stand to benefit most from reading them are all but deprived of access to them. (Regarding your remarks about killing 12 people before "a light comes on", again I will refer you to the WAVE DANCER dive boat incident. Twenty people died in that accident, and to give you an idea about just how forgiving flag states can be, do you want to guess what kind of boat the offending skipper is running now? Hint: It's "white".)
Henning- Your point is valid too. There is a need for more joint responsibility from the owners and agents to be informed and inclined (dare I say, liable) to ensure that the captain and crew are able to do what is right and safe versus what is most convenient and inexpensive. The question then is how do you do that without having to quit your job every time the boss puts his foot down over something that is potentially unsafe? I think it is easier when a safety issue is obvious, but in the case of the Lady Candida, I doubt it ever crossed their minds that the laundry might set the boat on fire. (Not that I am making excuses, I just don't think there was malevolent negligence.)

Thanks for the support Kelly. I have a couple of comments to add though. One, Wave Dancer captain Philip Martin’s name has long been in the public domain. He was named in multiple lawsuits and the diving community in the U.S. insured his eternal infamy. We still don’t know anything about the former master of the Lady Candida and there is little chance that boat will be ever show up on a CV at any crew agency. So far as innocent ignorance of the dangers of dryer lint, there was no mystery surrounding the risks inherent in dryer vent ducting. According to National Fire Protection Association (NFPA) statistics, there are around 15,000 dryer fires which kill an average of 20 people in the U.S. each year. There were 4 well publicized cruise ship fires between 1992 and 1998 which killed 6 crewmembers and injured 146 crew and passengers. The laundry fire onboard the Carnival Cruise ship Ecstasy couldn’t be much better documented, it was live on national television as it burned just off Miami Beach. This fire prompted a very public NTSB investigation and a shipping industry information campaign designed to increase crew awareness of the dangers of laundry room fires. It is hard to imagine a maritime professional who was not aware of the risks or a marine firefighting course that did not mention the threat created by lint filled dryer vents. The owner and manager are already liable. Management is not a “get out of jail free” card for either. The problem lies with the fact that yacht management is not a mature industry, it is ill-defined, and bears little resemblance to the very well defined role of the commercial ship manager, who, these days, may easily find himself standing next to the captain and/or owner in court for far less egregious failures than the Lady Candida highlighted. There is already the legal basis for joint responsibility, there just isn’t much will to prosecute because as far as maritime casualties go, the pollution is negligible, fatalities are rare, and nothing disappears faster than a broken white boat. Flag states do not take yachts seriously. “They never leave sight of land, how much trouble can they get into” is the rule rather than the exception of how flags view their recreational spawn. Flag states and port state control authorities are often described as “tombstone agencies.” They see nothing, hear nothing, say nothing , and do nothing until the number of tombstones on their turf grows too large to ignore, or the name on one of them creates a firestorm of publicity. This laissez faire attitude is behind the lack of oversight which allows untrained captains to acquire licenses and incompetent ones to keep them. It leads underwriters to make their own rules - for better or for worse.

I completely agree that there should be better transparency and reporting about all marine incidents and a more diligent standard overall regarding safety and a structured code of ethics and professionalism within the industry. I think you make an important point that Yacht Management is a perfect tool for self regulation within the yachting industry which is in need of better vision and organization. If we do not set a standard for ourselves, we risk others doing it for us. In the absence of a pleasure vessel standard, we have already seen yachts loosely clumped in with a number of commercial regulations which are counter-intuitive for boats that are not engaged in commerce, yet apply to us anyway (like portions of ISM, ISPS and the looming MLC). When this happens, it is bad for everyone because it takes the pleasure out of pleasure vessels and drives yacht owners (ie: jobs) away. But while this conversation is going on here, there’s another going on about captains who are functioning alcoholics. It really is time for this industry to grow-up and start conducting itself like a community of professionals and not just some free for all fraternity party with a paycheck.

Summary - the Captain/Master is responsible for the vessel’s safety... But is it really his fault when he was most likely ignorant to his own faults? He has some tickets and sea time, so probably thought he was pretty good at what he did. But we ALL really do not know how good we are until we are tested to our limits - and he was obviously tested beyond his, and has leant from the experience. Hopefully everyone out there in the yachting world is tested via training and not reality, but saying that, I think it is true to say that many people in the yachting industry attend the necessary training because it is a requirement not a passion. In the case above, clearly the Master didn't have any desire to prepare for a fire. And then begs the question... how many of the thousands of yacht crew out there (with tickets or not) have actually had to fight a real fire, on a real boat, with real lives at risk? Fortunately I have not, but know someone who has on a yacht in the middle of the Atlantic. It was scary, time moves fast, and they were lucky to save the vessel - the engineer just so happened to be in the right place at the right time to be in a position to successfully fight the fire. Just imagine if every crew agent asked every prospective crew member if they have successfully fought a real fire (not training) and hired on this basis. Ninety percent (or more) would be out of work I am sure... and when a yacht crew are hired, does the insurance, management or owner know everyone's individual limits? Of course not... it would be ridiculous for them to assume this. So when it comes down to tickets, experience, or being a Master... the Master of Lady Candida may not have known how to gain control of the fire, but made the best executive decision of them all - to abandon ship. No lives were lost and no one hurt - the rest the insurance company can sort out, as that is what they are for - replacing material possessions, not lives. So what can we all learn from this incident? Simple – be prepared to accept that no matter what experience or training you have, you may be pushed beyond your limits, and this is when it is most important to know what to do.

“(T)he Captain/Master is responsible for the vessel’s safety... But is it really his fault when he was most likely ignorant to his own faults?” Ignorance is no excuse. The process of working one’s way up to master or any senior officer position involves serving under the observation of experienced and competent officers who have the ability to weed out those who lack the capacity and the motivation to take more responsibility. Until the advent of the yacht licensing schemes, the nautical licensing path was based on seatime, training, observation, recommendation, and finally, examination. By the time a master was christened he was as thoroughly vetted as anyone could be. The long path to command included thousands of drills and practical exercises. Leadership was developed by working under those who earned the position of leadership, and by being responsible for others of lesser rank. Fools, frauds, and those with poor judgment don’t usually last long in that kind of shipboard environment. The MCA yacht licensing scheme short-circuited that path and Lady Candida is the poster boat for a flawed process. What happened on that boat is most certainly the master’s fault. If, in his claimed 22 years experience he never studied his art to the point where he learned the value of knowing the operation of his own vessel, or the value of drilling for common emergencies, he failed miserably in fulfilling the duties and responsibilities that the privilege of holding a license conveys. The bottom line in this casualty is that luck, pure blind luck, was all that prevented a death onboard that yacht. Nothing the captain did reduced the chances of serious injury or death of his passengers or crew. Experiencing every possible casualty is not a prerequisite for command nor could it be, do you want every driver to have had a car wreck or every pilot to have survived an airplane crash? Having the knowledge and the will to analyze risks and prepare for casualties has always been a prerequisite however. It is part of the process of advancement and evaluation that is supposed to precede examination and issuance of a license. I agree with you that the captain did not know what he did not know. He was blessed by the MCA and RYA to take command in that tragic state of bliss is and they should have know that he did not know. That is, in my opinion, negligence of the most dangerous sort.

I agree with the Chief it is every crews responsibility to walk off a boat if it is unsafe. Just as it is every crews responsibility no matter the size, ... to upon joining a new yacht as where the fire extinguishers life-rafts, vent shut offs and other such safety equipment are, and to sight them and understand how it all works!!! If that is not the case tyo leave the yacht, explain to the captain why you are leaving and contact the relevant authority if there is one to inspect the yacht.
How would you feel if the next crew member wasn't as thoughtful as you and went to launch the life-raft or use the extinguisher and it didn't work or/and the crew didn't know what to do.
And by the way yes i have left a yacht before due to out of date safety equipment and insufficient crew training... and no at the time i could not afford to turn down a job, but i value my life over a bit of money!

Thanks Anon, you brought up some excellent points. It is not just good practice to know where the safety gear is and how it works, it is a legal requirement. It is the captain's legal responsibility to make sure you know what it is, where it is, and how it works. LY2 states "Prior to the first occasion of working on a vessel, each employee must receive appropriate familiarization training and proper instruction in onboard procedures. This could include, but not necessarily be limited to: mooring and unmooring; launching and recovery oof survival craft; evacuation from all areas of the vessel; donning of lifejackets; and use and handling of fire fighting equipment." At the risk of drawing this discussion out beyond what anyone can be reasonably expected to bear much longer, let me quote a paragraph from a mini-ISM manual I wrote a couple of years ago. "Familiarization means introducing a new crewmember to the way things are done on your vessel. They may come aboard with basic or even advanced safety training but your approach to familiarization will determine how that crewmember regards safety as long as they are onboard. Your own attitude is a new crewmember's first contact with the vessel's safety culture."